The NHS is under significant pressure this winter. The new year saw daily newspaper headlines on the winter crisis, while high rates of bed occupancy and cuts to social care are both causing extra pressures to build up across the NHS.
Underlying all of this is the growing number of patients who are ready to leave hospital but can’t do so without extra support. Delayed transfers of care (DTOCs), often (rather insultingly) called ‘bed-blocking’ by the media, have been steadily on the rise in recent years, with the numbers of days patients are delayed reaching record levels month after month.
These delays are not only distressing for the patients and their families, they can be risky. For older people, staying in a hospital bed for too long can lead to loss of muscle tone and a number of adverse effects. For the hospital, high numbers of DTOCs have a significant impact on their ability to run smoothly and there is a strong link between DTOCs and patients waiting for extended periods in the A&E department.
DTOCs are a complex issue and to fixate on one solution would be to miss the point. Here, I explore what the data tells us about delays, and outline what can be done to address the problem.
What is a delayed transfer of care?
NHS England defines patients as ready for transfer when:
a. A clinical decision has been made that the patient is ready for transfer AND
b. A multidisciplinary team decision has been made that the patient is ready for transfer AND
c. The patient is safe to discharge/transfer.
DTOCs are officially recorded by NHS England in two ways: a snapshot of the actual number of patients delayed at midnight on the last Thursday of every month, and the total number of bed days (overnight stays) during which patients were delayed. This data is collected monthly and available from 2010.
How DTOCs have changed over time
Between 2011/12 and 2014/15, the number of bed days used by patients who were delayed grew by 60 per cent. This means that by October 2016, over 4,500 acute beds and 2,200 non-acute beds were occupied by these patients at any given time. That is the equivalent of more than ten 650-bed hospitals.
Although this is a relatively small proportion of the total number of beds available in NHS hospitals, the impact of these patients on the operation of the hospital is significant, because by definition their discharge is delayed, and many are staying for lengthy periods of time. This means that even very small fluctuations in these numbers can make a very big difference, resulting in a cycle of chaos which leads to ultimately sub-optimal care for patients.
The chart below shows how the number of delayed days across the NHS has grown since December 2010, as well as the type of organisation responsible for the delay.
Why are we waiting? The causes of DTOCs
As the data shows, the NHS had remained responsible for the majority of DTOCs over time, but the proportion for which social care are responsible has grown by 84 per cent since December 2010.
The data also allows us to explore the reasons for delays. The most significant change since November 2010 has been an increase in the number of days delayed due to patients waiting for a care package to be available either at home (172 per cent increase) or in a nursing home (110 per cent).
While the reduced availability of social care is often highlighted as the cause of DTOCs, 57 per cent of the delays occurred because of issues in the NHS.
DTOCs: the tip of the iceberg
DTOCs have a tight definition and as a result the reported figures often only represent a partial picture of the volume of patients that could be cared for in other settings.
We examined audit data from three members of our New Cavendish Group of small and medium-sized hospitals and a large database of snapshot audits undertaken by the Oak Group – a specialist company that conducts reviews of admissions and inpatient stays using a standard and validated approach.
The data showed a significant difference in the New Cavendish Group hospitals between the declared level of DTOCs and the number of patients actually medically fit for discharge. For example:
- In one small rural hospital, an audit of inpatients excluding critical care and maternity found that, of 277 patients, 14 per cent (40) met the DTOC criteria but that in fact 29 per cent (80) of patients were medically fit for discharge. Interestingly, there were also 13 per cent (35) of patients who were not medically fit for discharge but could nevertheless have been looked after in other appropriate settings, such as a nursing home.
- In another small rural hospital there were 45 medically fit patients, of whom only 15 were counted as DTOCs according to the strict interpretation of the guidance.
- In a more extreme case in a larger hospital, 335 patients were reviewed out of 650 beds in total. Of these, 65 per cent (218) were found to be medically fit, of whom only 6 per cent were going home that day. The snapshot of DTOCs that month declared only 56 for the month of the audit.
Other information and audits show a similar pattern. The Oak Group have undertaken audits across a large number of acute and community hospitals covering over 7,500 bed days. Again, these audits confirmed that significant numbers of patients could be cared for elsewhere, for typically 50-60 per cent of the acute bed days examined. The challenge is that just 19 per cent of bed days are associated with patients who can simply return home without any form of support; many others still require additional help, including high intensity nursing home care. A further 28 per cent could go home with a range of nursing and social care support, rehabilitation or clinical input, while 12 per cent require long-term supported live-in nursing or residential care. The remainder need rehabilitation, intermediate care and other specialist services. A small percentage need hospice or other palliative care. Many of these alternative services are provided by the NHS.
So what conclusions can we glean from this?
As demonstrated above, many patients are prevented from leaving because they need more out-of-hospital support to help them recover. But the latest National Audit for Intermediate care estimates that there is just half the capacity of intermediate care required, with signs that bed-based components of these are in decline.
The audits also indicate a significant opportunity for improvements in internal processes within hospitals. In the Oak Group’s data, over half the delays are related to issues with the hospital’s own processes and almost 20 per cent to shared issues about planning, documentation and transport.
Indeed, the system itself can create delays. A complex array of factors are at play and poorly designed processes, high volumes of work, shaky administration and a lack of clear pathways can all exacerbate the problem. These range from simple issues, such as having the drugs ready for the patient to take home, to more complex ones, such as delays in getting diagnostic results or a lack of therapy services at weekends. I recently heard of one trust where a member of staff was employed solely for the purpose of dealing with the paperwork associated with the legal requirement trusts have to notify social services of a patient’s discharge date.
One important implication from looking at our case study hospitals is that once maternity, paediatrics, cancer and other beds that cannot be used for emergencies are taken into account and the impact of patients waiting for discharge is allowed for, in one example a 650-bed hospital actually only had fewer than 250 beds available to accommodate all its emergency patients. This makes the system extremely fragile. What looks like efficiency is actually the opposite.
Two important messages should also be taken from this. We need to beware a narrative that fixing social care will fix the problems of the NHS. It won’t, but it would help. Secondly, it cannot be assumed that alternatives to hospital will save large amounts of money unless far more radical changes to the system are made.
Tackling the problem is not easy, but there are some clear learning points:
1. Define the real problem and measure it
Data that actually captures the real issue, rather than the current bureaucratic mechanisms for allocating blame, would be a good first step. As we have seen, the current system for reporting delayed discharges severely underestimates the numbers of patients in hospital who are ready to move elsewhere. Some hospitals have started to monitor the patients that could be cared for in other settings on a routine basis and are using this data to improve services.
2. Operational improvements within organisations
There are many interventions that are known to reduce the numbers of patients waiting for discharge, ranging from simple process improvements to bigger policy changes such as ‘discharge to assess’. However, it is possible that hospitals are so busy fire fighting that they lack the capacity to implement these measures and they may lack adequate support from community services.
3. Improve the interface between hospitals and other services
The role of social care in creating delays is significant and growing, but the interface with community services is a very significant factor, as is the availability of home support, therapies, access to diagnostics and other NHS services.
Housing associations, the voluntary sector and other agencies are useful allies, but they often find dealing with the NHS difficult and can’t solve the health sector’s problems alone.
4. Moving away from bureaucracy
One case in the audit demonstrated that substantial managerial and nursing time was being spent managing relationships and administrative processes with social workers. But there is another way, and there are examples of high-quality collaboration between social care, community services and hospitals, with some local authorities recording virtually no social care DTOCs.
The large and growing numbers of patients delayed in leaving hospital are both a cause and a symptom of problems in the smooth running of NHS hospitals. Yet the official data seriously underestimates the extent of these delays. And, as my colleague Richard Humphries at The King's Fund explains, there is also huge variation in local government and NHS performance in managing these delays. Learning from areas with fewer delays, improving systems and processes within hospitals, and making better use of data can all help. But against a backdrop of continued public sector austerity and growing demand for hospital care, progress in reducing the numbers of patients delayed in leaving hospital may be slow.